Top tips for a pediatric forehead laceration repair

Treating a pediatric forehead laceration in the ED raises questions about the best closure method and pain management.

Depending on the severity, it can also be tricky to decide when to involve a specialist. In this post on Healthcasts, a practitioner is seeking guidance on how to repair a toddler's laceration and what sedation to consider if the child requires it. 

What is your suggested approach? Log in or sign up to leave a comment and see the consensus.

A two-year-old male presents to the ED at a children's hospital on a late evening with a 3.5 cm vertical, slightly irregular laceration on the right forehead. The parents state this was the result of a fall in the bathroom at home. There is no concern for neurologic injury.

Questions

 Comments

Key takeaways about how to approach a pediatric forehead laceration repair :

• Repair choice depends on depth and demeanor
  The depth and gaping of the wound should guide treatment. Superficial lacerations may be closed with adhesive to reduce trauma, while deeper cuts often require sutures.
  
• Comfort measures often replace sedation
  Most practitioners favor topical anesthetics and gentle restraint over sedation, reserving ketamine or light sedation for anxious or uncooperative children.
  
• ED repair is usually appropriate
  The majority would repair the wound in the ED, consulting plastic surgery only for complex or high-visibility cases. Follow-up typically involves gentle cleaning, a topical antibiotic, and monitoring for infection.
  

Surgeon

"1. Depending on the depth, I would have a conversation with parents regarding possibly using glue. While it will leave a more prominent scar, the trauma to the child would be significantly less.

2. If using sutures, you could start with an EMLA cream prior to lidocaine. If that doesn’t work and the child is too scared, a light sedation could be considered.

3. I think any physician or physician assistant could successfully close this, depending on their training. Light layer of triple antibiotic and cover with a bandaid. Keep dry until sutures are out in 7-10 days."

Family Practice

"1. It depends on the depth and whether or not it is gaping or not. Sometimes on foreheads, we can use surgical adhesive. Otherwise, simple interrupted sutures work just fine.

2. Usually, sedation is not needed. Holding the patient in place typically is enough.

3. I can't think of a single time I have ever referred someone out of the ED to Pediatric Plastic Surgery, which is nearly impossible to get into for patients anyway. For those of us who work in rural environments, this would mean a 4-hour drive for the patient's family in order to see the one pediatric plastic surgeon in the state, just to be laughed at for referring a forehead laceration."

Family Practice

"1. The vertical component of the laceration adds a bit of decision-making to the calculus, and certainly the demeanor of the child. The parent is a large consideration in the approach. Superglue/dermabond would be a very reasonable strategy with the awareness that the scar could be revised in the future, under a more controlled environment if desired.

2. Ketamine would be ideal if the resources of the ED afford it.

3. The ED doctor should be well-trained to manage this routine case. Minimal follow-up instructions are necessary if superglue is used; it is not necessary to cover this laceration or avoid water, no matter what approach is used."

Family Practice

"1. Dermabond may be the least scarring; however, the running stitch can also be performed.

2. A topical anesthetic should be sufficient. If the child is not cooperative, you might restrain him as a burrito and let parents hold him for comfort.

3. An ED physician would be fine, but if the parents are overly concerned about scarring, a peds plastic surgeon could be called in. Follow up with a peds plastic surgeon would ensure proper follow-up and wound care to minimize scarring."

Surgeon

"1. Primary closure with sutures

2. Could try swaddle restraint in a blanket. If the patient is too fussy, I would try conscious sedation.

3. Probably on call peds plastic surgeon since this is front and center on the forehead. For wound care, apply topical antibacterial ointment qd. Clean with running water; do not scrub or be rough on the wound. Do not use an occlusive dressing. Contact the provider if signs of infection appear."

What repair and sedation techniques do you recommend? Review the full case on Healthcasts and leave a comment to help your peers.